In the cross hairs of the political debate between market forces and government intervention remains an interesting alternative. The public utility regulation of healthcare. Regardless of where you have planted your flag, there are considerations worthy of a public dialogue and at the very least--an appreciation. The dismal science can be quite illuminating when trying to unravel historical precedence and speculate on the most advantageous way forward...

The roots of economic theory are deep and profound. Threads from theories of Cynic philosophers weave together Laissez Faire world views and lingering political debates regarding the differentiation between coercion and voluntary transactions.

The latter defined as only occurring when it benefits both participants.

"Why do people give to beggars, he was asked, but not to philosophers? "Because they think they may one day be lame or blind, but never expect that they will turn to philosophy." To a young man who complained that he was ill suited to study philosophy, Diogenes said "Why then do you live, if you do not care to live well?"

Of grammarians, he was astonished that they desire to learn everything about the misfortunes of Odysseus but nothing about their own. Of mathematicians, that they keep their eyes on the heavens and overlook what is at their feet. Of orators, that they speak of justice but never practice it. When asked why he alone praised an indifferent harp player, Diogenes replied "because he plays the harp and does not steal."--Diogenes the Cynic

There remains a difference, after all, between pointing a gun at another's head and demanding 'Your money or your life,' and threatening to withhold bread from a starving person unless she consents to pay the market price" -- Barbara H Fried

Public utility regulation has historically shaped the US regulatory state and even more importantly health law as we know it. The rise of public utility was shaped out of a counter measure to laissez-faire economics--the belief that self-interest and profit motives should be "left alone" without governmental interference--and driven soley by market forces.

Public utility regulation required businesses impacting pubic interest to ascribe to what has been described as a "affirmative obligation". There are many historical precendents like the Interstate Commerce Act and Emergency Medical Treatment and Active Labor Act (EMTALA)--requiring hospitals to treat all comers--as a public interest.

...that all must be served, adequate facilities must be provided, reasonable rates must be charged, and no discrimination must be made-- Bruce Wyman Professor of Law Harvard University 1911

The law makes a powerful argument for free markets in "matters not vital to the life and well-being of mankind the laws of society may be left free to operate, without limits by sovereign power but in all that has to do with the necessaries of life the protection of the sovereign is extended"

Monopolistic Industries such as railroads and electric plants, as well as water works, banks, insurance companies, and housing interests, serve an important human need and as such the market power to exploit consumers--could be characterized as a public utility.

Noticably absent from the list is medicine but if you consider the simple state of medicine at the time, its regulation would not have been of prime importance. There were not many curative therapies at the time so economics was not a driver or even regulatory bodies granting professional licensure. There is also direction in the Public Service Corporation document that industries identified as public callings may change and evolve over time.

The present programme of organized society is to see to it that those who have gained a substantial control of their market shall not be left free to exploit those who look to them to supply their needs. -- Bruce Wyman

Many countries consider their health care systems as public utilities and demonstrate better outcomes at lower costs. Is a rate-setting centralized government payment system a worthwhile solution as single payer advocates suggest? Market-orientated solutions don't address informational asymmetries where patients are always going to be on the short-end of complicated and technical decision making appropriate in free market exchanges.

There are features of the market such as an inability for a consumer to shop around for best bargains, collusive pricing, and the emergency nature of entering the market--that may yield untraditional definitions of monopolies.

​We need to follow the thread of historical progress in the evolution of medicine. Once a charitable entity what we have in the modern day is a powerful market force with a powerful profit motive. What about market concentration where market power allows abusive pricing? Think of hospital markets and consolidation of power or the RUC. If you don't think the alarming rate of integrated medical systems is a bell-weather of purchase power and anticompetitive consolidation--you might need another "think".

​It might be time to look at historical measures to help shape and form healthcare in the modern age...

Thoughtful discussions about content development and outcomes analytics that apply the principles and frameworks of health policy and economics to persistent and perplexing health and health care problems...